1. Course Ante: HN 205
Course Title: DESIGNING AND PLANNING
NUTRITION PROGRAMS
Contact Hours: 20L 20S (Credit 1)

2. SUMMARY OF MODULE
• This module examines the causes and
consequences of nutritional disorders of
public health significance and looks at some
different intervention strategies available to
alleviate and prevent these.
• The module also covers various skills and tools
that we can use to gather pertinent
information, the project cycle to facilitate
planning and looks at some key intervention
models.

3. MODULE AIMS
• To explore nutrition related public health in the
country and to examine possible reasons for
variations nutrition-related ill-health.
• To provide tools, and experience of their use, for
information-gathering, problem identification,
project design and monitoring and evaluation.
• To develop practical skills for the design,
implementation, monitoring and evaluation of
intervention strategies.

4. LEARNING OUTCOMES
• At the end of this module, it is expected that
the successful student is able to:
• Discuss in detail the causes and outcomes of
disorders of public health significance
• To argue the principles and limitations of a
diverse range of interventions to maintain or
improve the nutritional status at the
population and community levels.

5. LEARNING OUTCOMES...
• Identify, and use, tools that are required to
conduct situation assessments and to plan
appropriate intervention strategies for
defined nutritional problems
• Critically evaluate existing interventions and
programmes

6. Background
• Child undernutrition is a serious and
persistent problem contributing to over 1/3
of
deaths among children under 5 years of age
• and is an underlying cause in one-fifth of
maternal deaths.
• The children who survive are more vulnerable
to infections and have compromised physical
growth, impaired cognitive development and
reduced lifetime earnings.

7. Background ….
• To reach the Millennium
Development Goals (MDG)
maternal and child nutrition
needs to improve at a rapid pace.

8. Millennium Declaration
• In 2000, 189 nations made a promise to free
people from extreme poverty and multiple
deprivations.
• This pledge became the eight Millennium
Development Goals (MDGs) to be achieved by
2015.
• In September 2010, the world recommitted
itself to accelerate progress towards these
goals.
(http://www.beta.undp.org/content/undp/en/
home/mdgoverview.html )

9. Millenium Development Goals
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV / AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development

10. Background ….
• Experts are calling for urgent and
evidence-based program action at
greater scale to prevent
undernutrition in children by
targeting pregnancy and the first two
years of life.

11. Background ….
• This development window of
opportunity (pregnancy and the first
two years of life) is when nutrition has
the greatest effect on child health,
growth and development;
If action is not taken during this period,
the damage can be irreversible.

12. Background …
• Moreover, there is general agreement that
effective interventions exist and are available
to prevent and treat undernutrition.
• If coverage of these evidence-based
interventions increases and reaches a greater
number of women and children, there could
be substantial reductions in undernutrition
and death.

13. Causes of Undernutrition
Malnutrition is the world’s most serious public
health problem and the single biggest
contributor to child mortality.
The conceptual framework on causes of
malnutrition illustrates the causes of
undernutrition and mortality.

14. Immediate causes…
Although the causes of malnutrition and death
can be traced back directly to
• inadequate dietary intake and
• diseases,
Or a combination of the two
The underlying and basic causes can be found
at each level in the society, for example:

15. Causes of malnutrition…
At the household level due to:
– poverty and lack of land or income-generating
opportunities leading to inadequate access to
food
– inequitable intra-household food distribution
– poor child-feeding practices
– poor hygiene
– poor access to health facilities
– poor child care due to heavy workload of women.

16. Causes of malnutrition…
At the community level due to:-
• inadequate opportunity for income
generation
• low purchasing power
• poor health care delivery systems
• poor availability of potable water
• inadequate agricultural extension services
affecting both crop and livestock production.

17. Causes of malnutrition…
At the national level due to:-
• unfavorable agricultural and pricing policies
• ineffective application of existing policies
• inadequate food storage practices for both
short-term and strategic reserves
• poor communication and transport systems
• inadequate accountability and transparency in
senior positions.

18. Underlying causes…
Underlying the immediate causes are
elements including:
• food insecurity,
• inadequate care of mothers and
children and
• poor availability and quality of water,
• sanitation and
• health services.

19. Causes of malnutrition…
In their efforts to reduce undernutrition,
NGOs often work directly on the
• underlying and basic causes of
undernutrition at the
community,
household and
individual level

20. Aim is to improve
• food security,
• care practices,
• health and
• the environment and
• address social challenges such as gender and
other inequities.

21. Nutrition Programmes ..
Nutrition Programs therefore aim at
addressing the existing nutritional
problem by designing interventions
that can either be:
• preventive (Preventive Approach) or
• Curative (Recuperative Approach)

22. Preventive Approach
A preventive nutrition approach is one
that targets all members of a
vulnerable population, regardless of
nutritional status of individual
children, to prevent undernutrition
and its consequences

23. Preventive Approach…
• Such population‐based preventive strategies
are recommended for communities that have
a high prevalence of undernutrition.
• Preventive programs are especially important
where there are high rates of stunting, which
is often irreversible, and therefore needs to
be addressed before it occurs.

24. Preventive Approach…
• Promoting and protecting growth for
all children is proven to be more
effective at reducing undernutrition
in the population than intervening
only on an individual basis after a
child is already undernourished

25. Preventive Approach…
• Most preventive nutrition programs focus on
children during the “development window of
opportunity” years of conception through age
2,
• This is the period when children are growing
most rapidly, are most vulnerable to growth
faltering and are most responsive to nutrition
interventions.

26. Recuperative Approaches
Recuperative approaches are those that provide
treatment to children who are
undernourished, including:
• Therapeutic feeding and medical care for
children with severe acute malnutrition
(SAM), and
• Supplementary feeding and medical care for
children who are moderately undernourished
The purpose is to bring the child back to a
normal nutritional status.

27. Recuperative Approaches
• Recuperative programs are most
appropriate in areas with high
prevalence of moderate acute
malnutrition (MAM) and Severe
Acute Malnutrition (SAM) and very
high prevalence of underweight.

28. MAM
• MAM is indicated by moderate wasting:
WFH ≥‐3 Z‐scores and <‐2 Z‐scores, or
MUAC ≥115 and <125 mm.
Children with MAM have a higher risk of
death than well‐nourished and at‐risk
children and need nutrition support.

29. SAM
• SAM is indicated by bilateral pitting edema or
severe wasting: WFH <‐3 Z‐ scores or MUAC
< 115 mm (MUAC used only on children > 6
months of age).
Children with SAM are highly vulnerable and
have a high mortality risk. These children
need immediate medical and nutrition
intervention.

30. Development Window of Opportunity:
Pregnancy to Age 2
• The risk of undernutrition, though present
throughout life, is heightened at certain
stages of the life cycle, in particular during
pregnancy, lactation and the first 24 months
of life.
• This period, from pregnancy until a child’s 2nd
birthday, during which children are most
vulnerable to undernutrition and the
accompanying irreversible deficits in growth
and development,

31. Development window…
• This period also presents a crucial
window of time during which
undernutrition can be prevented

32. Development Window…
• Because they are growing so rapidly,
children at this age are very responsive
to nutrition interventions that promote
growth and prevent undernutrition.
• Focusing on children under 2 years of
age presents a great opportunity to
intervene, promoting adequate growth
and devt. when they are most able to
benefit.

33. Gender and Other Factors in
Undernutrition
In addition to vulnerable points in the life‐
cycle, there are
• geographic,
• socio‐economic and
• gender‐based constraints to undernut.
Over 80% of the world’s undernourished
children live in just 20 countries,
concentrated in sub‐Saharan Africa and
South Asia

34. Gender….
In both regions, gender inequities
substantially influence poor maternal
and child feeding practices and
undernutrition.
These inequities stem from inadequate
attention to the needs and roles of
women, resulting in:
• inadequate care for pregnant and
lactating women,

35. Gender…
• lack of education,
• poor self‐confidence,
• low economic status and
• a workload that allows little time for
modifying practices to improve
nutrition.

36. Gender….
• To be effective, programs may have
to address a range of factors
affecting the care giving
environment and dynamics of the
household, such as women’s
workload.

37. Nutrition interventions
• Nutritional interventions refer to
programmes/strategies aimed
specifically at improving nutritional
situation in a community.

38. Nutrition interventions…
Malnutrition is caused by a lot of factors (refer
conceptual framework of causes of
malnutrition).
While governments begin to tackle these
monstrous problems, the extent of
malnutrition can be lessened by a number of
nutrition programmes and health strategies.
These are not alternative approaches but should
be co‐ordinated efforts that proceed
simultenously.

39. Nutrition interventions…
• Thus, while the government grapples
with the problems of poverty and
deprivation, some direct intervention
programmes aimed specifically at
improving nutrition can be
implemented.

40. Nutrition interventions…
The nutrition interventions which can be used
are:
1. Food fortification or enrichment
• The term fortification is used here is for the
addition of one or more nutrients to a food
for the purpose of improving its nutritional
value.

41. Fortification
• fortification refers to "the practice of
deliberately increasing the content of an
essential micronutrient, ie. vitamins and
minerals (including trace elements) in a food
irrespective of whether the nutrients were
originally in the food before processing or not,
so as to improve the nutritional quality of the
food supply and to provide a public health
benefit with minimal risk to health,"

42. Enrichment
• Enrichment is defined as "synonymous
with fortification and refers to the
addition of micronutrients to a food
which are lost during processing.

43. 1. Fortification…
• The advantages of fortification are that it can
improve the nutritional status of people
without any special action or change of
behaviour on their part and that it is usually
fairly inexpensive.

44. Fortification
• Iodine deficiency disorder (IDD) is the single
greatest cause of preventable mental
retardation. Severe deficiencies cause
cretinism, stillbirth and miscarriage. But even
mild deficiency can significantly affect the
learning ability of populations.
• Iodine is added to salt

45. Fortification…
Folic Acid
• Folic acid (also known as folate) is necessary
for maturation of red blood cells and synthesis
deficiencies lead to neural tube defects
(NTDs).
• In many industrialized countries, the addition
of folic acid to flour has prevented a
significant number of NTDs in infants.

46. • Niacin
Is added to bread to prevent pellagra
• Vitamin D is a fat soluble vitamin .
Foods that it is commonly added to are
margarine, vegetable oils and dairy products
• Fluoride the fortification of water supplies
with fluoride for prevention of tooth decay
and maintaining adequate dental health

47. Others
Some other examples of fortified foods:
• Calcium is frequently added to fruit juices,
carbonated beverages and rice.
• White rice is frequently enriched to replace
lost nutrients during milling or adding extras
in.
• "Golden rice" is a variety of rice which has
been genetically modified to produce beta
carotene.
• Sugar and margarine -fortified with vitamin A

48. Difficulties & disadvantages of
fortification…
1.It is necessary to find a food suitable for
fortification; one that passes through a
limited number of manufacturing or
processing plants where a nutrient can be
added, and is consumed at regular intervals
by the nutritionally vulnerable groups of the
population

49. Difficulties & disadvantages of
fortification…
2. Fortification is only desirable if the deficiency
to be corrected is fairly prevalent / the
nutrient to be added is very cheap.
Ideally the addition of the nutrient should not
cause any marked increase in the cost of the
food to the consumer.
It is obvious that any addition will add to the cost
but this may be borne either by the
government or the manufacturer, or the very
modest rise in the price of the commodity.

50. 2. Medicinal nutrients
The provision of specific nutrients in medicinal
form to groups of population is another way
to control malnutrition.
All the vitamin and mineral nutrients can be
used in this way. Any nutrient that is suitable
for fortification could as an alternative be
given medicinally to groups of the population.

51. Medicinal…
• The provision of iron tablets to pregnant
women attending antenatal or prenatal
clinics has been successfully practiced in many
countries for a long time.
• Fluoride tablets taken by children on a
regular basis are an effective way of limiting
dental caries in areas where local water
supply is low in fluoride (containing les than
0.5 ppm).

52. Medicinal…
• The provision of high-dose capsules of vitamin
A to children every 4 to 6 months as a means
of preventing xeropthalmia is being
increasingly practiced.
• In some countries niacin tablets to prevent
pellagra are regularly issued in certain
institutions.

53. Advantage…
• The advantage is that the nutrient can be
selectively administered to those at risk
whereas with fortification many well-
nourished persons not requiring additional
quantities of the nutrient receive it.

54. Disadvantages
• The disadvantage of this method compared
with fortification is that the delivery system is
of necessity more difficult and much more
expensive.
• When medicinal nutrients are provided in a
control programme it is impossible to reach
all those in need, and it is often the most
vulnerable people who are the most difficult
to reach.

55. 3. Supplementary foods and feeding
programmes
• It is recognized that the weaning period is a
critical one from a nutritional point of view.
• Breast milk alone is adequate for the first 4 to
6 months, and then while breastfeeding
continues other foods need to be introduced.

56. Supplementary foods and feeding programmes
Thus there is a period between about 5 months
of age and up to about 3 years of age during
which the infant or young child needs more
than breast milk but cannot do well on the
• limited number of meals and the
• type of food that older members of the
family may be consuming.

57. Supplementary foods and feeding programmes
In areas where poverty and malnutrition
exist, and especially in urban or densely
populated rural areas, supplementary
feeding programmes may be useful in
the control of childhood malnutrition.

58. Supplementary foods and feeding programmes
Unless supplementary foods and supplementary
feeding programmes are either
• highly subsidized or
• provided to poor families,
They will fail to help the most vulnerable group
of the population.

59. Supplementary foods and feeding programmes
Foods used in supplementary feeding
programmes should be:
• locally produced as far as possible;
• they should fit in with cultural food habits and
practices,
• meet nutritional needs

60. Supplementary foods and feeding
programmes…
Wherever possible supplementary
feeding programmes should include
nutrition education

61. Nutrition education:
The basis of any nutrition education
programme should be to encourage the
consumption of a nutritionally adequate
diet and to stimulate effective demand
for appropriate foods.

62. Nutrition education:
• An inadequate total intake of food by
young children (an energy deficiency) is
the main cause of malnutrition in Africa.
• Therefore, initial advice might be to
continue feeding the infant with the
same food as before but to do this more
frequently or to provide just a little
more of the food.

63. Nutrition education:
This advice should be more
acceptable to parents than the
attempt to make major, often
unrealistic changes in the diet.

64. Priority points for nutrition education in many African
countries might include:
• More frequent feeding of young children with
existing foods
• Increased amounts of foods at each meal for
children during the weaning and post-weaning
period
• Greater consumption by children of whatever
legumes are available and commonly
consumed by the family

65. Priority points for nutrition education
• Inclusion of foods such as groundnuts that are
rich in protein and provide a concentrated
source of energy;
• Encouragement of breast-feeding and
discouragement of bottle-feeding (i.e. the
protection and promotion of breast-feeding);
• Increase use of foods rich in carotene (dark
green leafy vegetables, yellow fruits and
vegetables) by young children in areas where
vitamin A deficiency is a problem;

66. Priority points for nutrition education
• Attendance by pregnant women at clinics
where iron and other supplements are
available and where the progress of
pregnancy can be checked;
• Encouragement of families to attend with
their young children at under-fives and similar
clinics, and to follow the growth of children;

67. Priority points for nutrition education
• Provision of information about the need for
immunizations and where these can be
obtained;
• Information that will help to reduce infectious
diseases, which often contribute to
malnutrition.

68. ESSENTIAL NUTRITION ACTIONS (ENA)
The ENA are seven affordable and evidence‐
based nutrition interventions delivered at
health facilities and communities to improve
the nutritional status of women and children.
The ENA provide a holistic framework on which
to base nutrition programming.

69. ESSENTIAL NUTRITION ACTIONS (ENA)
• The ENA framework maximizes coverage of
these interventions by delivering key
messages and services through multiple
contact points in relevant areas:
• nutrition,
• health and
• social sector programs,
The ENA focus on six critical contact points:

70. Six critical points..
1. Prenatal visits,
2. Delivery care,
3. Postpartum care for mothers and infants,
4. Immunization,
5. Sick‐child visits and
6. Well child visits (including counseling and
growth monitoring and promotion [GMP]).

71. The seven ENAs
The seven ENA are:
1.Promotion of optimal breastfeeding during
the first six months
2. Promotion of optimal complementary feeding
starting at 6 months with continued
breastfeeding to 2 years of age and beyond
3. Promotion of optimal nutritional care of sick
and severely malnourished children
4. Prevention of vitamin A deficiency in women
and children

72. The seven ENAs…
5. Promotion of adequate intake of iron
and folic acid and prevention and control
of anemia for women and children
6. Promotion of adequate intake of iodine
by all members of the household and
7. Promotion of optimal nutrition for
women

73. Details of the seven ENAs

74. 1. Promotion of optimal breastfeeding during
the first six months
• Promote early initiation of breastfeeding (i.e., within
one hour of birth); do not give pre‐lacteal feeds
• Promote exclusive breastfeeding (EBF) for the first
six months of life (i.e., no other liquids or foods)
• Promote breastfeeding on demand, day and night
(i.e., usually 8‐12 times per day) for an adequate
time at each feeding; offer the second breast after
infant releases the first
• Practice correct positioning and attachment of infant
at the breast
• Promote good breast health care

75. 2. Promotion of optimal complementary feeding starting at 6
months with continued
breastfeeding to 2 years of age and beyond
• Continue frequent, on‐demand breastfeeding
through 24 months of age and beyond
• Introduce complementary foods at 6 months
of age
• Prepare and store all complementary foods
safely and hygienically

76. 2. Promotion of optimal complementary feeding…
• Increase food quantity as child gets older
 6‐8 months: 200 kcal/day from complem. foods
 9‐11 months: 300 kcal/day from compl. foods
 12‐23 months: 550 kcal/day from compl. foods
• Increase frequency of feeding complementary
foods as child gets older
6‐8 months: 2‐3 meals per day
9‐23 months: 3‐4 meals per day, 1‐2 snacks per
day (as desired)

77. 2. Promotion of optimal complementary feeding…
• Increase food consistency and variety
gradually as child gets older
• Feed a variety of foods daily to ensure
adequate nutrient intake, including animal
products, fortified foods and vitamin A‐rich
fruits and vegetables
• Practice responsive feeding (i.e., feed infants
directly and assist older children, encourage
children to eat, do not force feed, minimize
distractions, show love to children by talking
and making eye contact)

78. 3. Promotion of optimal nutritional care of sick and
severely malnourished children
• Continue feeding and increase fluids during
illness
Child under 6 months of age: increase frequency of
EBF
Child 6‐24 months: increase fluid intake, including
breast milk, and offer food
• Increase feeding after illness until child regains
weight and is growing well
• For diarrhea: provide zinc supplementation for
10‐14 days, according to WHO protocol

79. Promotion of optimal nutritional care…
• For diarrhea: provide low osmolarity oral
rehydration solution (ORS) to children over 6
months
• For measles: provide vitamin A treatment,
according to WHO protocol
• Refer severely malnourished children for
treatment according to WHO protocol,
through community‐based management of
acute malnutrition (CMAM), inpatient care, or
other appropriate program

80. 4. Prevention of vitamin A deficiency in women
and children
• Breastfeed children exclusively for the first 6
months, and continue breastfeeding until the
child is 24 months or older
• Treat xerophthalmia and measles cases with
vitamin A, according to WHO guidelines
• Provide high‐dose vitamin A supplementation
to children 6‐59 months of age, every six
months according to WHO guidelines

81. Prevention of vitamin A deficiency in women
and children…
• Provide post‐partum high‐dose vitamin A
supplementation to women as soon as
possible after delivery:
 If breastfeeding, within eight weeks of
delivery
 If not breastfeeding, within six weeks
of delivery

82. Prevention of vitamin A deficiency in women
and children…
• Promote consumption of vitamin A‐rich foods,
including liver, fish, egg, red palm oil, dark
yellow or orange fruits (e.g. mango ripe and
dried, papaya ripe and dried, apricots fresh
and dried, persimmon), dark green leafy
vegetables, and orange or dark yellow fleshed
vegetables, roots and tubers (carrots,
pumpkin, squash, sweet potatoes).
• Promote consumption of vitamin A‐fortified
foods, where available

83. 5. Promotion of adequate intake of iron and folic acid
and prevention and control of
anemia for women and children
• Promote intake of iron‐rich foods, especially
animal products and fortified foods
• Provide iron/folic acid (IFA) supplementation
to all pregnant women; continue
supplementation for three months post‐
partum in areas with anemia prevalence
greater than 40 percent
• Provide IFA supplementation for children

84. Promotion of adequate intake of iron and
folic acid…
• Deworm children over 12 months of age,
pregnant women after the first trimester and
lactating women according to WHO protocol in
areas where parasitic worms are a common
cause of anemia
• Prevent and control malaria:
Intermittent preventive treatment for pregnant
women
Long‐lasting insecticidal nets (LLINs) for women and
children

85. 6. Promotion of Adequate intake of iodine by
all members of the household
• Promote consumption of iodized salt
• Supplement pregnant and lactating
women and children 6‐24 months of age
with iodized oil capsules when iodized
salt is not available, according to WHO‐
recommended doses

86. 7. Promotion of optimal nutrition for women
• Consume more food during pregnancy and lactation
Pregnancy: 285 extra kcal/day (one additional
small meal each day)
Lactation: 500 extra kcal/day (1‐2 additional small
meals each day)
• Increase protein intake during pregnancy and
lactation (e.g., beans, lentils, legumes, animal source
foods, oilseeds)
• Provide IFA supplementation for all pregnant
women, according to WHO protocol
• Treat and prevent malaria

87. 7. Promotion of optimal nutrition for women…
• Deworm during pregnancy (after 1st
trimester)
in areas where parasitic worms are a common
cause of anemia
• Provide post‐partum vit. A supplementation
• Promote consumption of iodized salt
• Supplement pregnant lactating women with
iodized oil capsules when iodized salt is not
available, according to WHO recommended
doses

88. THANK YOU